From the Guidelines
Perioperative management of hypercoagulable states requires careful anticoagulation planning to balance bleeding and thrombotic risks, with a focus on individualized patient-centric care. Patients with known hypercoagulable conditions, such as Factor V Leiden, antiphospholipid syndrome, protein C/S deficiency, or malignancy, should continue therapeutic anticoagulation as close to surgery as safely possible, as recommended by the American College of Chest Physicians 1.
Preoperative Management
- For patients on warfarin, discontinue 5 days before surgery and bridge with therapeutic low molecular weight heparin (LMWH) such as enoxaparin 1 mg/kg twice daily, stopping 24 hours before surgery, as suggested by the American College of Chest Physicians 1.
- Direct oral anticoagulants (DOACs) should be stopped 48-72 hours preoperatively depending on renal function and bleeding risk, as recommended by the American College of Chest Physicians 1.
- Mechanical prophylaxis with sequential compression devices should be started immediately before surgery, as recommended by the American College of Chest Physicians 1.
Postoperative Management
- Postoperatively, restart prophylactic anticoagulation (enoxaparin 40 mg daily or equivalent) within 12-24 hours when hemostasis is adequate, transitioning to therapeutic dosing within 48-72 hours for high-risk patients, as recommended by the American College of Chest Physicians 1.
- Early mobilization is essential, as it can help reduce the risk of venous thromboembolism (VTE) and improve overall outcomes, as suggested by the National Institute for Health and Care Excellence 1.
- Laboratory monitoring with anti-Xa levels may be appropriate for patients on LMWH, as recommended by the American College of Chest Physicians 1.
Risk Assessment and Management
- The management approach should be anchored on the assessment of patients’ risk for thromboembolism and surgery/procedure-related bleeding, as recommended by the American College of Chest Physicians 1.
- The risk classification schemes should be empiric, requiring prospective validation, but aim to provide individualized perioperative management, in particular to help determine if perioperative anticoagulation interruption is needed and, if so, among VKA-treated patients, if heparin bridging is needed, as suggested by the American College of Chest Physicians 1.
- Extended-duration pharmacologic thromboprophylaxis (4 weeks) with LMWH is recommended for patients undergoing major open or laparoscopic abdominal or pelvic surgery for cancer who have high-risk features, as recommended by the American Society of Clinical Oncology 1 and the American College of Chest Physicians 1.
From the Research
Perioperative Management of Hypercoagulable States
- The management of hypercoagulable states in the perioperative period involves assessing the risk of bleeding and thromboembolism for each patient individually 2.
- For patients taking direct oral anticoagulants (DOACs), a standardized approach to perioperative management involves classifying the risk of procedure-related bleeding as minimal, low to moderate, or high risk 3.
- For minimal bleeding risk procedures, DOACs may be continued or discontinued on the day of the procedure, while for low to moderate bleeding risk procedures, DOACs should be discontinued 1 day before the operation and restarted 1 day after 3.
- For high bleeding risk procedures, DOACs should be stopped 2 days prior to the operation and restarted 2 days after 3.
- Laboratory testing to measure preoperative DOAC levels may be useful in determining whether patients should receive a DOAC reversal agent prior to an emergent or urgent procedure 3.
Anticoagulation Management in Special Populations
- In patients with renal impairment, the use of enoxaparin versus unfractionated heparin (UFH) for venous thromboembolism prophylaxis is still a topic of debate, with some studies suggesting an increased risk of major bleeding with enoxaparin 4.
- In intensive care unit (ICU) patients, UFH was associated with a higher rate of mortality compared to enoxaparin, although there was no difference in the prevalence of deep vein thrombosis (DVT) and pulmonary embolism (PE) between the two groups 5.
General Principles of Perioperative Anticoagulation Management
- Each case should be assessed individually with proper risk assessment, monitoring, and plan for perioperative and postoperative anticoagulation 2.
- Clinical evidence for the management of these patients is relatively scarce, and clinicians are often assessing each individual case with minimal guidance 2.